Section 29-2335. SERVICES AND SUPPORTS -- PATIENT REHABILITATION PLAN AND REVIEW STANDARDS

 

2335.1 If admitted, the rehabilitation plan shall be developed for each patient by the interdisciplinary team based on the comprehensive assessment within ten (10) days of the admission, unless the patient is admitted to a non-hospital detoxification program where the length of stay is expected to be less than ten (10) days. Patients shall receive necessary treatment and rehabilitation services during the assessment process.

 

2335.2 For patients admitted to a Level III detoxification unit the rehabilitation plan for the detoxification stay shall be developed for each patient by the interdisciplinary team within seventy-two (72) hours of admission. Continuing care plans for post-discharge rehabilitation services shall be written as part of the discharge summary in accordance with §2350 and 2352.

 

2335.3 The patient shall participate in the development of the rehabilitation plan and shall sign and date the plan.

 

2335.4 The individualized rehabilitation plan shall be recorded in a standardized format utilized by the facility or program and shall include, at a minimum, the following information:

 

(a) Diagnosis;

 

(b) Criteria for discharge from the program based on completion of the established course of treatment, and/or transfer to a less intensive/restrictive level of service;

 

(c) A list of any agencies currently providing services to the individual and family including the type(s) of service and date(s) of initiation of those services;

 

(d) A list of needs and strengths;

 

(e) Specific individualized, behaviorally stated goals for each patient;

 

(f) The treatment regimen, including specific services and activities that will be used to meet the treatment and rehabilitation goals;

 

(g) An expected schedule for service delivery, including the expected frequency and duration of each type of planned service encounter;

 

(h) The name and title of personnel who will provide the services;

 

(i) The name and title of the primary care counselor and case manager;

 

(j) A description of the involvement of family members or significant others, where appropriate;

 

(k) The identification of specific patient responsibilities;

 

(l) The patient’s level of services;

 

(m) The patient or legal guardian’s signature on the plan; and

 

(n) Signatures of all interdisciplinary team members participating in the development of the rehabilitation plan.

 

2335.5 A program staff member shall be assigned to coordinate the development, implementation and required revision of the patient’s individualized rehabilitation plan.

 

2335.6 A rehabilitation team, including but not limited to staff responsible for goals identified in the patient’s rehabilitation plan, including at least one addictions counselor and the assigned case manager, shall meet and review the rehabilitation plan on a regular basis:

 

(a) At least every fifteen (15) days while the individual is in Level III if the length of stay is 30 days or less; or more frequently, if changes in the individual’s functioning and/or rehabilitation activities occur before the end of the fifteen (15) day period;

 

(b) At least every thirty (30) days in Level III if the length of stay is more than 30 days and in Level II; or more frequently if changes in the individual’s functioning and/or rehabilitation activities occur before the end of the thirty (30) day period; and

 

(c) At least every ninety (90) days while the individual is in Level I, or more frequently if changes in the functioning and/or rehabilitation activities occur before the end of the ninety (90) day period.

 

2335.7 Pursuant to §2335.6, the rehabilitation team shall evaluate and document, in the patient’s record, the patient’s progress toward the treatment and rehabilitation goals, the appropriateness of the services being provided, and the need for the patient’s continued participation in specific program levels and services.

 

2335.8 The interdisciplinary team shall conduct an annual assessment of any person receiving ongoing services during the previous twelve (12) months:

 

(a) The written annual assessment shall include:

 

(1) A summary of the initial presenting problem and the strengths and needs at the time of admission;

 

(2) A summary of the services delivered during the past year and the patient’s response and progress;

 

(3) A description of the patient’s current social, family, education, vocational, and legal status; personal support systems; use of community resources; emotional and behavioral status; and substance use patterns; and

 

(4) The identification of current needs and problems that may warrant continued service delivery.

 

(b) A revised rehabilitation plan shall be developed as part of the annual assessment.

 

2335.9 The facility or program shall develop and implement written policies and procedures for referral activities not normally provided by the facility or program that shall, at a minimum:

 

(a) Establish protocol for referral and transfer of a patient from one program to another;

 

(b) Describe conditions under which referrals are made for ancillary and special services, including but not limited to psychological, psychiatric, medical, vocational, social services, legal services, educational and recreational services, and self-help and peer support groups;

 

(c) Establish procedures for obtaining patient consent for referral activities;

 

(d) Describe the methods to assist in the patient’s follow through after a referral has been made;

 

(e) Establish continuing communication and coordination between providers;

 

(f) Require documentation in the patient’s record of each referral made and the result of the referral;

 

(g) Support quality service delivery to patients who are dually diagnosed; and,

 

(h) Establish procedures for referral of persons ineligible or inappropriate for services to an appropriate facility or program, including but not limited to those persons who require acute medical detoxification services, medical services, or long term psychiatric services when the facility or program does not offer the level of care required for patients who are assessed as needing these services.

 

 

source

Final Rulemaking published at 47 DCR 9341 (November 24, 2000), adopting Emergency and Proposed Rulemaking published at 47 DCR 7708, 7757 (September 22, 2000).